Pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment

Pulmonary artery pseudoaneurysm after thoracic radiation therapy: A case report and review of the literature

Pulmonary artery pseudoaneurysm (PAP) is a rare cause of hemoptysis. Potential causes include trauma, infection, or medical interventions. There is a risk of rupture, which is associated with a high mortality rate. We describe a 72-year-old patient, with a past medical history of a lung carcinoma for which she was treated with chemoradiotherapy 6 years prior, who presented with hemoptysis. She was hemodynamically stable and there were no other complaints. CT angiography of the thorax showed a PAP originating from a branch of the right pulmonary artery in the previously irradiated area. The patient was successfully treated by an embolization with plugs. Treatment of lung carcinoma with chemoradiotherapy can result in the development of a PAP. Clinicians should be aware of this complication, even years after the therapy. In literature, only a few cases of PAP in patients treated with (chemo)radiotherapy for lung cancer are described, with a maximum interval up to 7 years.

Endovascular management of a pulmonary artery pseudoaneurysm secondary to mucormycosis: A case report

The development of pulmonary artery pseudoaneurysm (PAP) secondary to pulmonary mucormycosis (PM) is exceedingly rare. Without immediate intervention, PAPs can result in life-threatening hemorrhage as these weakening vessels are prone to rupture. To avoid such an occurrence, procedures that restrict blood flow to the vulnerable region are typically performed. The present case study details the effective employment of endovascular coil embolization in treating a patient with PAP due to pulmonary mucormycosis.

Pulmonary pseudoaneurysm in the setting of concurrent COVID-19 and pulmonary mucormycosis: A rare case report

Key Clinical Message

This case illustrates the possible danger of PAP emergence in individuals with a confluence of conditions capable of inducing vascular impairment, like COVID-19, pulmonary mucormycosis (PM), and diabetes.

Abstract

Pulmonary mucormycosis (PM) is a highly lethal invasive infection. It is a rare complication of COVID-19 and is associated with a high mortality rate. Pulmonary pseudoaneurysm (PAP) is a severe manifestation of this condition, often resulting in death. Management involves endovascular therapy followed by surgery and appropriate antifungal treatment.

A Case of the Unveiling of Pulmonary Pseudoaneurysm Masquerading as a Lung Mass

Pulmonary artery pseudoaneurysm (PAP) is an abnormal dilatation of the pulmonary vessels. They can mimic the appearance of lung nodules on chest X-rays and noncontrast CT imaging of the chest. We present a case of PAP masquerading as a lung mass for five years before presenting as a pulmonary hematoma. Our patient was an elderly male who presented to the emergency department with dizziness and weakness. He had been on regular follow-ups with annual noncontrast CT scans for a stable lung mass for the past five years. A contrast-enhanced chest CT scan on presentation showed a right lower lobe pseudoaneurysm ruptured into the pleural space with hemothorax, which was confirmed on subsequent chest CTA. The patient underwent an emergent right lower lobe resection and recovered uneventfully. Differentiating a PAP from a lung nodule is challenging and is often missed even by radiologists. A nodule or mass along the pulmonary arterial tree should raise suspicion and trigger further contrast-enhanced imaging, especially angiography, to confirm the diagnosis.

Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds

In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.

Role of Interventional Radiology in the Management of Non-aortic Thoracic Trauma

Trauma remains a leading cause of death for all age groups, and nearly two-thirds of these individuals suffer thoracic trauma. Due to the various types of injuries, including vascular and nonvascular, interventional radiology plays a major role in the acute and chronic management of the thoracic trauma patient. Interventional radiologists are critical members in the multidisciplinary team focusing on treatment of the patient with thoracic injury. Through case presentations, this article will review the role of interventional radiology in the management of trauma patients suffering thoracic injuries.

Hemoptysis after COVID: Pulmonary artery pseudoaneurysm treated with endovascular coiling

Pulmonary artery pseudoaneurysms are a rare but life-threatening cause of hemoptysis. These are saccular dilatations of the pulmonary artery which do not involve all the three layers of the vessel and are prone to rupture. PAPAs are most commonly associated with infections but may also be caused by vasculitis, lung fibrosis, pulmonary hypertension and a multitude of other causes. CT pulmonary angiography is the diagnostic modality of choice allowing delineation of the PAPA, underlying cause and allowing planning of further management. Although treating the underlying cause is an important part of management, endovascular intervention is required in cases with hemoptysis. Long COVID is an entity that is still under evaluation. It has multisystem involvement. We describe the case of a 30-year-old teacher with hemoptysis after COVID who was diagnosed with a PAPA of segmental branch of left upper lobar pulmonary artery and treated with endovascular embolization with coils and glue. His hemoptysis has stopped since then. He also had pulmonary fibrosis and growth of multidrug resistant Klebsiella pneumoniae in sputum. These were treated medically and he has resumed his work as a teacher.

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PAPAs must be suspected in patients with history of COVID-19 and coexisting infection who also complain of haemoptysis.

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Endovascular management of PAPAs may prove to be more efficient especially in the setting of critically ill patients.

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Treating the underlying cause of PAPAs is an essential feature of management of patients.

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Pulmonary artery dilatation on CT is not always only pulmonary hypertension.

Hugh-Stovin syndrome: the 'incomplete Behcet's disease'. A case study of a young adult with recurrent pulmonary embolism and pulmonary arterial aneurysms

Hugh-Stovin Syndrome (HSS) is characterized by recurrent thrombophlebitis and multiple pulmonary and/or bronchial artery aneurysms indistinguishable from the cardiovascular features seen in Behcet's disease (BD). Our case describes a 30-year-old male with recurrent pulmonary embolism and bilateral pulmonary aneurysms. Autoimmune, hypercoagulable, and infectious work up were negative. Elevated inflammatory markers and absence of the typical clinical findings seen in BD led to the diagnosis of Hugh-Stovin syndrome (HSS). Immunosuppression using steroids and azathioprine led to clinical response. Anticoagulation was continued based on risk/benefit ratio.

Thoracic Trauma, Nonaortic Injuries

Trauma is one of the leading causes of death worldwide. Approximately two-thirds of trauma patients have thoracic injuries. Nonvascular injury to the chest is most common; however, while vascular injuries to the chest make up a small minority of injuries in thoracic trauma, these injuries are most likely to require intervention by interventional radiology (IR). IR plays a vital role, with much to offer, in the evaluation and management of patients with both vascular and nonvascular thoracic trauma; in many cases, IR treatments obviate the need for these patients to go to the operating room. This article reviews the role of IR in the treatment of vascular an nonvascular traumatic thoracic injuries.

Pulmonary artery pseudoaneurysms: endovascular management after adequate imaging diagnosis

Pulmonary artery pseudoaneurysms (PAPs) are rare serious vascular abnormalities mostly due to infections and trauma, although other conditions such as vasculitis, neoplasms, or inflammatory lung diseases can also predispose to this entity. Endovascular techniques such as embolization or covered stent placement have mostly substituted surgical approaches, for their lower invasiveness and greater security, mainly in patients with life-threatening hemoptysis. The purpose of this manuscript is to describe the imaging findings of pulmonary artery pseudoaneurysms and their endovascular management including tips to help interventional radiologists. PAP should be diagnosed as accurately and early as possible in order to prompt endovascular management of further life-threatening hemoptysis. KEY POINTS: • Pulmonary artery pseudoaneurysms (PAPs) are rare serious vascular abnormalities that may represent a life-threatening condition, mainly due to Staphylococcus, Streptococcus, or Mycobacterium tuberculosis. • Radiologists should know the imaging findings of PAP in order to make an accurate and early diagnosis to prompt endovascular management of further life-threatening hemoptysis.

Pulmonary Artery and Intercostal Artery Pseudoaneurysms After Penetrating Injury

Traumatic pulmonary artery and intercostal artery pseudoaneurysms are rare pathologies that can occur after a penetrating injury. Most times, there is only one pseudoaneurysm that needs addressed. Options for management include simple observation, endovascular intervention with coiling, embolization, and stenting, and surgical intervention ranging from ligation to pneumonectomy. We present the case of a 20-year-old male who developed multiple pulmonary artery pseudoaneurysms and an intercostal artery pseudoaneurysm after sustaining a single gunshot wound to the chest. After multiple episodes of bleeding from several pseudoaneurysms, the patient ultimately required a pneumonectomy.

Fatal rupture of pulmonary artery pseudoaneurysm after thoracic radiation therapy against lung squamous cell carcinoma: A case report and literature review

Pulmonary artery pseudoaneurysm is a rare but fatal condition. It has been associated with lung cancer, abscesses, and radiation therapy. Identification in patients with hemoptysis is critical, and timely interventional therapy is warranted.

Pulmonary Complications of Cardiac Surgery

Cardiothoracic surgery posits an arrangement of large, significant hemodynamic, and physiologic alterations upon the human body, which predisposes a patient to develop pathology. The care of these patients in the postoperative realm requires an astute physician with deep understanding of the cardiopulmonary system, who is able to address subtle developing problems promptly, before the patient suffers further sequelae. In this review, we describe the presentation and management of an assortment of important complications which occur in the pulmonary system. In addition, we aim to shed better light upon how the physiology of a patient responds to the condition of cardiothoracic surgery.

Three-dimensional printing in a patient with pulmonary artery pseudoaneurysm and complex congenital heart disease-A case report

3D-printing is a powerful tool in patients with complex anatomy undergoing cardiac surgery.

Penetrating chest trauma after attempted suicide: An extraordinary behavior of a posttraumatic pulmonary artery pseudoaneurysm

Posttraumatic pulmonary artery pseudoaneurysm is a very rare, yet potentially lethal complication after thoracic trauma. Pulmonary artery pseudoaneurysm is associated with high mortality. Still literature highlights that untreated, lesions can enlarge, rupture, and lead to exsanguination and death. We present a case of a posttraumatic peripheral pulmonary artery pseudoaneurysm with complete disappearance after one year. This case confirms that conservative treatment can be an effective option in asymptomatic and stable patients.

Pulmonary Artery Pseudoaneurysm in a Child With β-Thalassemia Major

Pulmonary artery aneurysms and pseudoaneurysms are rare vascular anomalies in children that can lead to massive hemoptysis resulting in severe morbidity and even mortality. High level of clinical suspicion, timely diagnosis, and prompt management are important for a better outcome. Here, we report a case of a 14-year-old adolescent with β-thalassemia major who presented with life-threatening hemoptysis due to pulmonary artery pseudoaneurysm and was successfully treated with coil embolization.

An unusual presentation of pulmonary artery sarcoma: Several pseudoaneurysms with massive hemoptysis

A 53-year-old woman was admitted to the emergency department with sudden onset of massive hemoptysis. She had previous history of dyspnea and cough for two months. She had no history of chronic disease, smoking, or use of anticoagulant and antiplatelet drugs. On arrival, she was tachycardic and tachypneic, but her body temperature was normal. Chest X-ray showed enlarged right hilus and multiple nodular opacities predominantly in the left lung basis. Computed tomography (CT) scan of the chest demonstrated massive intraluminal filling defect extending from the right pulmonary artery through the main and left pulmonary arteries. Pulmonary artery sarcoma (PAS) was the preliminary imaging-based diagnosis. However, CT also revealed presence of several pseudoaneurysms arising from the distal branches of the left pulmonary artery encased by metastatic nodules. Although hemoptysis is an uncommon presentation for patients with PAS, accompanied pseudoaneurysms were the main reason for massive hemoptysis. Differentiation of PAS from bland thromboembolism could be challenging on CT. Herein reported case provides an additional imaging feature that may utilize differentiating pulmonary artery sarcoma from bland thrombus.

Pulmonary Artery Pseudoaneurysms in the Setting of Gout Polyarthropathy: A Case Report

Pulmonary artery pseudoaneurysm is a dangerous pathology often missed as a differential and on imaging. With a 50% mortality rate early detection and intervention are critical to patient outcome, rendering diagnosis based on clinical grounds to be of paramount importance. A high index of suspicion should be placed on patients presenting with unprovoked hemoptysis, hemorrhage or hemothorax. Knowledge of the common causes of pulmonary artery pseudoaneurysms is also important; however, it is integral to note spontaneous occurrences in patients with no known risk factors. Herein, we report a case of an unprovoked pulmonary artery pseudoaneurysm in a 72-year-old male with no known risk factors or causes for the pathology. Additionally, we review the pathophysiology behind the potential association of polyarthritic gout as a cause of pulmonary artery pseudoaneurysms. To the best of our knowledge this is the first reported link between the two diseases, providing grounds to widen literature and increase diagnoses of pulmonary artery pseudoaneurysms.

Massive Hemoptysis from a Pulmonary Artery Pseudoaneurysm during Cardiac Surgery

Massive hemoptysis is a life-threatening condition usually related to a pathology of the bronchial arteries. Pulmonary artery pseudoaneurysms represent a relatively rare cause of severe airway bleeding, but are associated with a mortality rate of over 50%. A case of massive intraoperative hemoptysis treated with temporary occlusion of the right pulmonary artery and delayed endovascular occlusion of the feeding segmental artery is described.

A 29-Year-Old Woman With Severe Sepsis and Hemoptysis

A 29-year-old woman presented with a 1-week history of fever, weakness, anorexia, darkened urine, and mild cough. The patient described her cough as nonproductive and without hemoptysis. She had no chest pain. The patient's medical history was significant for x-linked hypophosphatemia, renal stones, migraine headaches, and chronic back pain managed on prescribed oral opiates for some time. She reported regular cigarette smoking, but denied illicit or IV drug use or any recent travel or sick contacts. The patient also had no known pertinent family history.

Acquired pulmonary artery pseudoaneurysms: a pictorial review

Pulmonary artery pseudoaneurysms (PAPs) are uncommon but potentially lethal. They may be incidentally discovered on imaging, or following massive haemoptysis if they rupture, with high risk of mortality. The most frequent causes of PAP are trauma and infectious disease. Vasculitis, in particular Behçet's disease, neoplasm, congenital disease and pulmonary hypertension are rarer causes of PAP. A PAP can be suspected from chest X-ray and contrast CT, but requires confirmation by CT angiography. Arteriography is no longer performed for diagnostic purposes, but can be useful in preparing endovascular occlusion of the PAP. In rare cases, surgery is necessary. The aim of this pictorial review was to illustrate the most common causes of acquired PAPs.

Traumatic pulmonary artery pseudoaneurysm with concomitant pulmonary embolism

Traumatic pulmonary artery pseudoaneurysms are rare, with only 25 previously documented cases. We present a case of traumatic pulmonary artery pseudoaneurysm in a 27-year-old male with concomitant pulmonary embolism which presented eight days after injury. He was treated with coil embolization of the pseudoaneurysm along with inferior vena cava filter placement. This unique case of concomitant traumatic pulmonary artery pseudoaneurysm and pulmonary embolism made management challenging given the competing priorities.

Pulmonary Artery Pseudoaneurysm: A Rare Cause of Hemoptysis in a Child

Aneurysms and pseudoaneurysms of pulmonary vasculature are uncommon occurrences that contribute to mortality and morbidity, without timely diagnosis and intervention. We report a fatal massive hemoptysis in a child due to a consolidation-related pulmonary arterial pseudoaneurysm, an extremely rare phenomenon.

Ultrasound-Aided Diagnosis of Pulmonary Artery Pseudoaneurysm in a Pediatric Patient

Pulmonary artery pseudoaneurysm (PAP) is an uncommon entity associated with high mortality if left untreated. PAPs are most often acquired secondary to trauma, inflammation, infection, or malignancy. The most common presentation is hemoptysis, but many patients are asymptomatic. Because of the increased risk of enlargement and rupture, timely diagnosis and intervention is necessary. Imaging plays an essential role not only in diagnosis of this entity but also in intervention. We describe a case using gray-scale and color Doppler imaging providing sonographically aided diagnosis and follow-up of a clinically silent PAP in a pediatric patient.

Vessels of the Central Airways: A Bronchoscopic Perspective

Blood supply of the tracheobronchial tree is derived from a dual system involving pulmonary and bronchial circulation. Various primary and secondary abnormalities of central airway vasculature can present with patterns that are distinct during bronchoscopy. These patterns maybe visualized during bronchoscopic evaluation of a patient with hemoptysis or as an incidental finding during an airway examination for other indications. Thorough knowledge of airway vasculature abnormalities and recognition of possible underlying pathophysiology is vital for the bronchoscopist. This review is a comprehensive description of vascular anatomy of the airway and the different vascular abnormalities that can be encountered during bronchoscopy.

Endovascular treatment of a pulmonary artery pseudoaneurysm caused by Swan-Ganz catheter deployment in an anticoagulated patient

We present a case report of an anticoagulated 78-year old man presenting a pulmonary artery pseudoaneurysm following Swan-Ganz catheter deployment after an aortic valve and aortic root replacement. Diagnosis was established by cone beam CT angiography and catheter angiographyand embolisation was achieved via a combination of plug and glue. This case emphasises the importance of endovascular techniques in the management of iatrogenic pulmonary pseudoaneurysms and shows the benefit of using highly hemostatic polymeric agent in anticoagulated patients to obtain a rapid and effective occlusion.

Imaging of vascular pseudoaneurysms in the thorax and abdomen

INTRODUCTION

This review article illustrates a spectrum of arterial pseudoaneurysms that may occur in various locations throughout the thoracoabdominal region. This article discusses the common etiologies and typical clinical presentations of arterial pseudoaneurysms as well as the imaging modalities employed in their diagnosis and potential treatment options.

OBJECTIVE

The goal of this review article is to familiarize radiologists with the diagnosis of thoracoabdominal arterial pseudoaneurysms, the prompt identification and treatment of which are crucial in this patient population.

CONCLUSION

In summary, a thorough understanding of the etiologies, imaging characteristics, and clinical implications of pseudoaneurysms can help optimize identification and management of this spectrum of disease.

Endovascular coil embolisation of a giant pulmonary artery pseudoaneurysm from a gunshot wound

A 38-year-old female was brought to the trauma emergency room after sustaining multiple gunshot wounds to the right chest and abdomen. She had pulmonary contusions involving the right lung and a haemopneumothorax initially managed with chest tube placement. A few weeks into her hospitalisation, she was found to have a giant right pulmonary artery pseudoaneurysm, which corresponded to a bullet tract. The pseudoaneurysm was causing a steal phenomenon and impaired perfusion of the right middle lobe and right lower lobe. Endovascular coil embolisation of the pseudoaneurysm was performed with restoration of perfusion to the right lung.

Stenting as a rescue treatment of a pulmonary artery false aneurysm caused by swan-ganz catheterization

Pulmonary vascular injury is a rare but life-threatening complication of Swan-Ganz catheterization. We report an 82-year old patient who underwent right heart catheterization by a balloon-tipped catheter because of suspected pulmonary hypertension. After deflation of the catheter in the wedge position, hemoptoe appeared associated with acute respiratory insufficiency requiring respiratory support by intubation and mechanical ventilation. Pulmonary angiography showed the formation of a false aneurysm of a segment artery of the left lower lobe. Immediate interventional therapy was performed by the implantation of two coated coronary stent grafts into the injured pulmonary artery thereby excluding the false aneurysm. Bleeding was stopped by this interventional approach while antegrade blood flow was maintained. Long term follow-up after 3 months showed an effective treatment with a completely thrombotic false aneurysm. However, despite oral anticoagulation and dual antiplatelet therapy, graft patency could not be achieved after 3 months. In summary, implantation of coated stents is a feasible and safe approach for the acute and long term treatment of potentially life-threatening condition of a pulmonary artery false aneurysm while treatment to achieve long term patency of the affected vessel still remains an issue to be resolved.

Pulmonary artery pseudoaneurysm after a left upper sleeve lobectomy

A 55-year-old man was re-admitted for persistent hemoptysis and high fever three weeks after an initial left upper sleeve lobectomy for a central squamous lung cancer tumor. Pulmonary artery pseudoaneurysm and pulmonary infection were confirmed by multidetector computed tomography angiography and subsequent emergency completion pneumonectomy. The development of pulmonary artery pseudoaneurysm, secondary to post-operative pulmonary infection and pulmonary vascular manipulation, is rare and prompt surgical manipulation is mandatory.

Medical pneumonectomy: interventional bronchoscopic and endovascular management of massive hemoptysis due to pulmonary artery pseudoaneurysm, a consequence of endobronchial brachytherapy

Endobronchial brachytherapy serves as an excellent adjunct to standard external beam radiation therapy. The high dose of local radiation is still used to manage airway obstructions at some institutions, despite the well-known risks of airway fistulae to the esophagus or cardiovascular structures. A less reported complication is the development of a pulmonary artery pseudoaneurysm into the mainstem bronchi. The formation of an arterial pseudoaneurysm can lead to massive hemoptysis, which often is fatal. We present a case of massive hemoptysis due to this complication of brachytherapy managed entirely through bronchoscopic and endovascular techniques.